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I ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X3;13/ <br /> i <br /> __, ___.THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ps <br /> F Application is` hereby made' to the' San Joaquin Local Health District fora permit <br /> to construct <br /> f and/or install the work herein described. This application is made in -compliance with San Joaquin <br /> County Ordinance No. 18 2 anis the Rules and Regulations of the San Joaquin Local Health District. <br /> . 1 � <br /> JOB ADDRESS/LOCATIONFS;f 0,' CENSUS TRACT <br /> Owner's Nam Phone <br /> Address <br /> �'•.. /Y City z_o?2f <br /> Contractor's Name �` <br /> LGl ,� ��lill f License # Phone <br /> L 6z <br /> .. <br /> . TYPE OF WORK (Check) : NEW WELLteFJ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /77 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE 1 DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial 6 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing <br /> ___Irrigation Ii Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> f Other Other Information l -_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. f <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL.: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withFall laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informati n is true to the best of my knowledge and belief. - -� <br /> SIGNER TITLE &W4�4_ <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> ' R DEPARTMENT USE ONLY <br /> PHASE I } <br /> APPLICATION ACCEPTED BY lQ � DATE ��- <br /> ADDITIONAL COMMENTS: --- <br /> PHASE II GROUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE a <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M �- <br />